<p> SYDNEY HERNIA CENTRE</p><p>MEDICAL INFORMATION </p><p>To give you meaningful advice and to plan for your consultation or surgery, it is helpful for us to obtain information about you.</p><p>We treat this information in a private and confidential manner. If you have a specific concern regarding your privacy please let us know. We abide by current Australian Privacy Legislation.</p><p>Many of our patients travel from the other side of town, the country, interstate and overseas. Having all of the information available ensures all goes smoothly.</p><p>Please fax back the completed form on 61 03 9527 1519 or email it back to us. You may also telephone us on 1300 HERNIA (1300 437 642).</p><p>If you are from Australia you will require a referral letter. Any other medical information will be helpful.</p><p>FAMILY DETAILS:</p><p>Family Name (Last Name): ______Given Name: ______D.O.B. ____</p><p>Address: ______Post Code: ______</p><p>Home Phone No.( )______Bus. ( ) ______Mob.______</p><p>Email: ______Fax: ______</p><p>Male Female Married Single </p><p>Occupation/Retired: ______Self Employed: YES/NO</p><p>FINANCIAL DETAILS:</p><p>Do you have: a) Private Hospital Insurance: YES/NO Details: ______b) Is this a WorkCare claim: Details please ______c) Do you have a Medicare Card: No: ______</p><p>Once you have contacted us and provided the above details we can give you an approximate quote for hospital and medical expenses.</p><p>PHYSICAL DETAILS:</p><p>Height (cms): ______Weight (kgs): ______Recent weight gain? (kgs): ______Recent Weight Loss? (kgs): ______</p><p>You can also send us a digital photograph of yourself and your hernia or even a hard copy.</p><p>YOUR HERNIA:</p><p>Describe the hernia in your own words. There is a diagram present which shows the site and side of your hernia or hernias.</p><p>Mark the site of your hernia with an “X”!</p><p>INGUINAL and FEMORAL HERNIAS</p><p>How long have you had the hernia? ______Is it painful? YES/NO</p><p>RIGHT GROIN</p><p>Is this your first RIGHT groin hernia? YES/NO</p><p>If not, how many previous RIGHT repairs have there been?____ and date of last repair: ______</p><p>Size of this hernia: ____ Small/Large or into the scrotum in males ____ </p><p>Can the hernia be pushed back in or go in by itself overnight: YES/NO</p><p>LEFT GROIN</p><p>Is this your first LEFT groin hernia? ____ YES/NO</p><p>If not, how many previous LEFT repairs have there been? _____ Date of last repair: ______</p><p>Size of this hernia: ____ Small/Large or into the scrotum in males ____ </p><p>Can the hernia be pushed back in or go in by itself overnight: YES/NO UMBILICAL, EPIGASTRIC HERNIAS</p><p>How long have you had the hernia? ______Is this hernia painful? YES/NO</p><p>Is this your first UMBILICAL, EPIGASTRIC/OTHER hernia? ____YES/NO</p><p>If not, how many previous repairs have been attempted on this hernia? ______</p><p>Date of last repair: ______was there a wound infection after last repair? ____YES/NO</p><p>Size of this hernia: Small/Large. </p><p>Can the hernia be pushed back in or go in by itself overnight: YES/NO</p><p>INCISIONAL HERNIAS</p><p>How long have you had the hernia? ______Is this hernia painful? YES/NO</p><p>Was the original operation for:</p><p>___Appendix ___Gallbladder ___Stomach ___Caesarian ___Hysterectomy ___Colon </p><p>___Other</p><p>How many repairs have been attempted on this hernia? ______Date of last repair: ______</p><p>Was there ever a wound infection? ___ Yes ___ No</p><p>Size of this hernia: ____ Small/Large. Does the hernia go back in when pushed or lying </p><p>YOUR HEALTH</p><p>List ALL medicines, pills and drugs that you have been taking recently especially anything with Aspirin. ______</p><p>HAVE YOU EVER HAD</p><p>A heart attack, angina pain, or any other heart problems Y N Y N High or low blood pressure / or medication for this Y N Shortness of breath or lethargy especially on walking up hills/ stairs Y N Lung problems or asthma medication Y N</p><p>Are you allergic to any medication? Y N Do you take Cortisone or related medicines? Y N Kidney or bladder problems Y N Diabetes Y N Digestion or bowel problems or bleeding Y N Jaundice or hepatitis Y N Tested HIV positive Y N Strokes, dizziness or blackouts Y N Are you the fainting type? Y N Do you smoke? How many per day? Y N Do you have any health problems now Y N List previous operations below List significant illnesses How would you assess your health? Have you had any recent test? Please supply details if possible!</p><p>REFERRAL</p><p>Name, address and phone number of General Practitioner or specialist to contact should additional medical information be required, so that we may report on your progress and aftercare. </p><p>Please let us know how you came to contact us e.g. internet, previous patient etc.</p><p>______</p><p>Please elaborate on the health questionnaire below: ______</p><p>______</p><p>______</p><p>______</p><p>______Patient Signature Date</p>